Advancing Chronic Care with Effective, Scalable Solutions (ACCESS)
Model Summary
1. Executive Validation and Strategic Context
The Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) model represents a watershed moment in Medicare payment reform, introducing the most structurally complex voluntary payment arrangement in CMS Innovation Center's history. Operating as a ten-year demonstration under Section 1115A authority from July 5, 2026, through June 30, 2036, ACCESS signals CMS's aggressive pivot toward technology-enabled, outcome-based chronic care delivery at unprecedented scale and complexity.
Strategic Significance and Market Impact
ACCESS fundamentally challenges the prevailing fee-for-service paradigm by creating condition-specific monthly payments that operate outside traditional Medicare payment methodologies. With nationwide scope covering four clinical tracks—Early Cardio-Kidney-Metabolic (eCKM), Cardio-Kidney-Metabolic (CKM), Musculoskeletal (MSK), and Behavioral Health (BH)—the model targets chronic conditions affecting over 60% of Medicare beneficiaries. The voluntary structure eliminates geographic constraints while introducing payment rates ranging from $7.50 to $35 per beneficiary per month, creating a potential $2-3 billion annual payment opportunity across all participants.
The model's alignment with the current administration's Make America Healthy Again (MAHA) initiative and Dr. Oz's CMS leadership provides strong political tailwinds. The emphasis on preventive care, chronic disease management, and technology-enabled solutions resonates with broader healthcare policy priorities focused on addressing America's chronic disease epidemic. However, this political alignment creates vulnerability to future administration changes, potentially affecting the model's ten-year trajectory and long-term viability.
Market Transformation Implications
ACCESS accelerates three critical healthcare market transformations. First, it institutionalizes technology-enabled chronic care delivery by requiring FHIR-based data exchange, remote monitoring capabilities, and digital patient engagement platforms. This technology mandate creates immediate market opportunities for digital health companies while potentially disadvantaging organizations lacking technological infrastructure.
Second, the model's complex operational requirements favor integrated delivery networks and larger health systems with sophisticated data analytics capabilities, care coordination infrastructure, and financial resources to manage payment withholding and performance risk. This structural bias toward larger organizations may accelerate healthcare consolidation trends, particularly affecting smaller independent practices and safety-net providers who lack necessary operational capabilities.
Third, ACCESS introduces novel risk mechanisms—Clinical Outcome Adjustments and Substitute Spend Adjustments—that penalize traditional Medicare billing patterns while rewarding technology-enabled care delivery. This creates fundamental tensions between ACCESS participation and existing revenue streams, forcing organizations to choose between traditional fee-for-service optimization and outcome-based payment strategies.
CMS Strategic Direction
The ACCESS model reflects CMS's broader strategic shift toward voluntary, technology-enabled payment models that emphasize clinical outcomes over process measures. Unlike previous CMMI models that often mandated participation or focused on cost savings, ACCESS prioritizes clinical improvement through technology adoption, patient engagement, and care coordination. The model's ten-year duration provides unprecedented stability for investment planning while allowing sufficient time to demonstrate meaningful population health improvements.
The integration with FDA's TEMPO pilot program represents an innovative intersection of Medicare payment policy and medical device regulation, potentially accelerating digital health technology adoption while creating new regulatory compliance requirements. This coordination between CMS and FDA signals federal commitment to technology-enabled healthcare transformation beyond traditional payment reform.
Stakeholder Impact Assessment
ACCESS affects multiple stakeholder categories differently. Integrated health systems with existing chronic care programs, robust data analytics capabilities, and strong physician alignment are positioned for substantial revenue growth and competitive advantage. Technology companies specializing in remote patient monitoring, telehealth platforms, and FHIR-based data exchange solutions face significant market expansion opportunities.
Conversely, smaller physician practices, rural providers, and organizations lacking technological infrastructure face substantial operational challenges and potential exclusion from participation. The model's complexity creates barriers to entry that may limit participation diversity, potentially undermining CMS's goals for nationwide chronic care improvement.
Medicare Advantage plans face competitive pressure as the model excludes MA beneficiaries while potentially demonstrating superior chronic care outcomes in traditional Medicare. This exclusion could influence beneficiary enrollment decisions and create market share shifts between traditional Medicare and MA plans in markets with high ACCESS participation rates.
2. Model Architecture and Temporal Dynamics
The ACCESS model operates through a sophisticated multi-track, multi-cohort architecture designed to test outcome-aligned payments across diverse chronic care domains while maintaining operational flexibility for participants and CMS evaluation requirements.
Core Structural Framework
ACCESS employs a Tax Identification Number (TIN)-level participation structure requiring Medicare Part B enrollment, effectively excluding DMEPOS suppliers and independent laboratories. Each participating TIN must designate a physician Clinical Director, creating a critical single-point-of-failure risk for program continuity. Organizations may participate in multiple tracks simultaneously, though multi-track discounts apply to prevent double-payment allegations, with discount percentages unspecified in the current RFA.
The four clinical tracks address distinct chronic care populations with varying complexity levels. eCKM targets early-stage cardio-kidney-metabolic conditions with prevention-focused interventions, while CKM addresses established disease requiring more intensive management. MSK focuses on musculoskeletal conditions using improvement-based measures rather than control targets, and BH addresses depression and anxiety through standardized screening instruments.
| Track-Specific Architecture | Track | Target Population | Payment Structure | Duration | Key Measures |
|---|---|---|---|---|---|
| eCKM | Early CKM conditions | Initial: $360/year, Follow-on: $180/year | 24 months maximum | BP control, BMI, HbA1c monitoring, LDL-C | CKM |
| Established CKM | Initial: $420/year, Follow-on: $210/year | 24 months maximum | BP control, BMI, HbA1c <7.5%, LDL-C targets | MSK | Musculoskeletal |
| $180/year | 12 months only | PROM-based improvement | BH | Behavioral Health | Initial: $180/year, Follow-on: $90/year |
24 months maximum
PHQ-9, GAD-7 improvements
Temporal Implementation Schedule
The ACCESS model launches with staggered cohort implementation designed to facilitate program management and evaluation. Cohort 1 applications opened January 12, 2026, with a deadline of April 1, 2026, and program commencement on July 5, 2026. Cohort 2 follows with a January 1, 2027 start date, after which quarterly cohort launches occur through April 1, 2033.
This rolling implementation schedule creates both opportunities and challenges for potential participants. Early cohorts benefit from first-mover advantages and longer program duration but face greater uncertainty regarding program requirements and CMS implementation support. Later cohorts can observe early participant experiences and benefit from refined operational procedures but may encounter saturated markets or modified program terms.
Payment Period Architecture
ACCESS introduces a novel bifurcated payment structure distinguishing Initial Periods (first 12 months of treatment) from Follow-On Periods (continuation care). Initial Period qualification requires both beneficiary treatment history (no treatment for specific conditions within two years) and clinical need (at least one OAP measure not at target). For eCKM and CKM tracks, referred beneficiaries qualify for Initial Period payments regardless of baseline target achievement, creating referral incentives.
The MSK track operates uniquely with no Follow-On Period, limiting participation to 12 months and creating patient turnover requirements for sustained revenue. This structure may encourage inappropriate patient cycling or discourage long-term relationship development, potentially conflicting with chronic care management best practices.
Reconciliation and Payment Cycles
CMS employs semi-annual reconciliation cycles with 50% payment withholding pending performance verification. Monthly payments represent one-twelfth of annual OAP amounts for Medicare's 80% portion, with cumulative disbursements capped at 50% of annual totals. This withholding structure creates substantial working capital requirements, particularly for organizations serving large ACCESS populations.
Reconciliation occurs approximately every six months, requiring submission of outcome measures data, substitute spend documentation, and beneficiary attribution verification. Processing delays could extend final payment determination by 60-90 days beyond reconciliation periods, creating potential cash flow gaps of 8-9 months between service delivery and final payment receipt.
Program Evolution and Modification Authority
Under Section 1115A authority, CMS retains broad discretion to modify ACCESS requirements, payment rates, and performance targets throughout the ten-year demonstration period. While participants sign binding agreements, CMS may implement changes through program updates rather than formal rulemaking, creating ongoing compliance uncertainty.
The model includes automatic escalation of Outcome Attainment Thresholds beginning at 50% in Year 1 with annual increases, though specific escalation rates remain unspecified. This progressive tightening of performance requirements could significantly impact financial projections and program viability for marginally performing organizations.